You may not realize that you’re taking too much of a popular pain reliever. The most widely used medication in the United States, acetaminophen (Tylenol), is effective in relieving mild to moderate pain and reducing fever—when used at the recommended dosage. When more than 4,000 milligrams of acetaminophen are used a day, however, it can harm the liver. Acetaminophen overdosage causes an estimated 56,000 visits to emergency facilities each year and is the most frequent cause of liver failure.

Although the problems have been recognized for years, they recently gained more scrutiny. The Federal Drug Administration has taken a closer look at the safety of over-the-counter and prescription medication containing acetaminophen. Last week, an FDA joint advisory committee gathered to discuss safety questions surrounding acetaminophen. They made several recommendations, such as lowering the maximum daily dosage and strengthening the labeling.

And, manufacturers may be asked to play a bigger role in helping prevent overdoses. One issue: many remedies contain acetaminophen along with other medications. Consumers may not be aware they are swallowing acetaminophen along with both prescription and over-the-counter remedies. A majority of acetaminophen-related deaths have involved opioid/acetaminophen combination products, such as acetaminophen/oxycodone (Percocet) and acetaminophen/hydrocodone (Vicodin). Typically, the package warning labels concentrate on the more potent opioid drug.

Although the FDA is not required to accept the recommendations of its advisory committees, it usually does so.

To help protect yourself from overdosing on acetaminophen, Daniel A. Hussar, PhD, Remington Professor of Pharmacy at the Philadelphia College of Pharmacy at the University of the Sciences in Philadelphia, offers these tips:

• Know that APAP is the abbreviation for the chemical name of acetaminophen and, if found on the list of ingredients, means the product contains acetaminophen.
• For occasional, modest pain, consider starting with a dose of 500 mg (rather than 1000 mg).
• Be aware there are two concentrations of nonprescription acetaminophen for children. The infant formulation is more concentrated than the formulation for older children. Make sure you understand the concentration level before giving medication to a child.
• Check the dose of acetaminophen that is included in any combination medication. Ask your pharmacist if you are uncertain.
• For over-the-counter cold and flu remedies, seek products that treat just the symptoms you have. For sneezing and a runny nose, for example, a product containing an antihistamine and a decongestant would be sufficient.

For more information on acetaminophen, see the Pharmacist Activist Newsletter. For information and support on relieving back pain, a very common pain complaint, see the Healia Back Pain Guide. And talk to others about treatment and relief at the back pain online health community and support group.

While back pain is one of the most common reasons for people to visit the doctor, a study published this week in The Lancet finds that imaging techniques such as X-rays that are commonly used for diagnosing back pain have no effect on the outcome for most patients. Even worse, some imaging techniques expose patients to low levels of radiation that may increase the risk of some cancers.

Researchers at the Oregon Health and Science University in Portland examined how more than 1,800 patients fared after visiting their family doctor with acute (severe but short-lived) or subacute (less severe but longer lasting) lower back pain. They found that patients who showed no sign of a serious underlying condition but whose doctors recommended lower back imaging by either X-ray, CT scan, or MRI showed no differences from those who did not undergo such imaging procedures on a wide variety of clinical outcomes including pain and functioning, quality of life, mental health, overall improvement and patient satisfaction.

X-rays and CT scans use radiation to create an image of the lower back and so they expose patients to low to moderate amounts of ionizing radiation, a risk factor for several cancers. While MRIs do not use radiation, they are significantly more expensive than the other techniques.

The researchers say that despite the fact that most patients who visit the doctor for lower back pain do not have any serious underlying condition causing the pain, doctors often order immediate imaging procedures to check for problems like herniated disks, muscle injuries, arthritis or broken bones anyway. They urged doctors to be more judicious when deciding which patients should be sent for X-ray, CT, or MRI, and reserve such procedures for cases in which there is a concrete sign of a problem that imaging may be able to diagnose.

An accompanying editorial by researchers at the University of Gottingen in Germany lists several reasons why doctors may order imaging for their patients with lower back pain without any indication that such a procedure is medically necessary. For one, patients often expect their doctors to order some kind of diagnostic test and may feel slighted if they do not. In fact, a recent study showed that 80 percent of people with low back pain said that, if given the choice, they would have imaging even without expected benefits. Additionally, fear of missing the rare case where a patient does have a serious medical problem that is not obvious on a physical exam and the structure of financial reimbursement incentives for doctors may also make it more likely for them to order such tests.

If you have low back pain and you visit the doctor, ask them if imaging is appropriate in your case. If the doctor identifies something in the physical exam that warrants such testing, then it is very likely worth the cost and/or radiation exposure to undergo the procedure. However, if the doctor does not have any concrete sign that imaging is warranted, or if he or she leaves it up to you, you may want to consider carefully whether imaging is really necessary. Keep in mind that most back pain improves within a few weeks with over-the-counter pain relievers and self-care.

For more information about lower back pain, see the Healia Health Guide on Back Pain. To share your story about back pain and find out what others have to say, join the Healia Health Community for Back Pain.

_{Photo: gogogadgetscott, Flickr, Creative Commons}

Every winter, around 30,000 people are treated for injuries that happened while shoveling snow or removing ice manually. The types of injuries sustained include sprains and strains, particularly in the back and shoulders, as well as lacerations and finger amputations.

Even worse, every time there is more than a dusting of snow and the temperature drops below freezing, the death rate from heart attacks goes up, as much as three times among men 35 to 49 years old. One of the main causes of this increase is snow shoveling.

Clearly, taking proper safety measures while shoveling snow is important. The following tips can help keep you safe from the first snow of the season to the final shoveling of the year.

For your heart:

• If you are in a high risk group for heart attack, you may want to talk to your doctor before you take on the task of shoveling snow. Those at the highest risk for a heart attack during physical exertion include anyone who has previously had a heart attack or who has heart disease, people with high blood pressure or high cholesterol levels, and people who lead a sedentary lifestyle.
• Avoid consuming caffeine (coffee, cola) or nicotine before beginning. These stimulants may increase your heart rate and cause your blood vessels to constrict, placing extra stress on the heart.
• Drink plenty of water while you are working. Dehydration occurs frequently while working in the cold because people tend to sweat a lot while wearing warm winter clothes. The air can also be very dry, even when there is snow on the ground.
• Dress in layers so you can remove layers as needed if you get hot.
• Start slowly and pace yourself, taking breaks when needed. When it is cold, people often try to hurry to get the job done, but that only increases the risk of injury or heart attack.
• If you experience shortness of breath, chest pain, or tingling in your arms, neck, or jaw, it may be a sign of a heart attack: stop working and call 911 immediately.

To avoid injury:

• Warm up your muscles for 10 minutes before shoveling by stretching out or walking in place. Warm muscles take longer to tire and are also less likely to be injured.
• Use a shovel that is appropriate for your height and strength. While a larger blade allows you to move more show at once, it also puts more strain on your body and makes your heart work harder.
• Try to push the snow instead of lifting it. If you must lift, protect yourself from back injuries by lifting correctly. Squat with your legs apart, knees bent, and back straight. Lift with your legs and tighten your stomach muscles as you lift the snow. Do not bend at the waist. Do not hold a shovelful of snow with your arms outstretched as this puts too much weight on your spine.
• Avoid twisting movements. Do not throw the snow over your shoulder or to the side, as this requires a twisting motion that stresses your back. If you need to move the snow to one side, reposition your feet to face the direction the snow will be going.
• Stand with your feet about shoulder-width apart for balance and keep the shovel close to your body. If it is icy, be especially careful when shifting your weight around quickly, such as when tossing snow from your shovel into a pile
• Listen to your body. Stop if you feel pain.

For more information on heart attack, see the Healia Health Guide for Heart Disease.

_{Sources: American Academy of Orthopedic Surgeons, 2007 http://orthoinfo.aaos.org/topic.cfm?topic=A00060; North Dakota State University, 1999 http://www.ext.nodak.edu/snow.htm}

_{Photo: bcmom, Flickr, Creative Commons}